Essay 369: Reduced fetal movements / PET

A 23 year old woman attends the day assessment unit at 34 weeks gestation because she has not felt fetal movements for 24 hours. (a) Discuss your initial clinical assessment [6 marks]. (b) Discuss your subsequent management if the fetus is viable but movements remain reduced [5 marks]. (c) She presents at 38 weeks gestation with BP of 148/98 mmHg, 3+ proteinuria and urine protein:creatinine ratio of 256 mg/mmol. Discuss your antenatal management [9 marks].

a)  An absent fetal movement is a cause of concern as it could be a warning sign for impending fetal death. I will ask further questions to assess the risk of stillbirth or fetal growth restriction (FGR).  Mutiple consultations regarding reduced fetal movements need to be ascertained.  I will also review other factors such as the presence of hypertension, diabetes and smoking.  I will also enquire whether this current pregnancy is told to have a growth restricted fetus or an abnormal fetus.  I will also ask regarding her past obstetric history of stillbirth or FGR.  

Fetal movements are subjective maternal perception of fetal movements. Therefore I would ask regarding her activity of the day as some woman may not be aware of the movements if they are preoccupied with a hectic activity.  

I will then proceed for an examination where I would palpate the abdomen for fundal height and measure the symphysio-fundal height.  The fundal height should be plotted using a customized chart.  This is the initial assessment to look for SGA fetus.  I would then check the presence of fetal heart by using a hand held Doppler device or a Pinard stetescope.

b)   If the fetus is viable and the history confirms of reduced fetal movements a Cardiotocograph (CTG) is then done to exclude fetal compromise.  If the CTG is reactive I will proceed to perform an ultrasound to assess the abdominal circumference, fetal weight to detect SGA fetus and also to assess liquor volume.  Scan for fetal morphology needs to be carried out if this was not done previously.  If there are evidence of growth restriction a serial measurement of fetal growth need to be carried out every 2 weeks and plotted on a customized growth chart.  An ongoing assessment is needed to 

c)  I will admit this patient as she has pre eclampsia. She needs a one to one care by the midwife.The senior obstetrician need to be alerted for early involvement and input.  I will start her on antihypertensive treatment oral Labetolol 200mg three times a day.  Blood need to be taken and sent for full blood count, urea, electrolytes, creatinine, urate, liver function test (LFT) and a clotting profile( if the LFT is deranged).  I will also quantify her proteinuria by obtaining a 24 hour urine collection.   Her blood pressure needs to be monitored every 15 minutes. A fluid balance chart needs to be charted hourly.  The presence of symptoms such as epigastric pain, visual disturbance, vomiting or headache need to be ascertained as she may require magnesium sulphate as a prophylaxis.  

Next I will assess the fetus by an abdominal examination to detect SGA.  An ultrasound to assess the fetal biometry and liquor volume is done and plotted on a customized growth chart.  The fetus needs to be delivered.  Therefore discussion need be done with the woman regarding the mode of delivery and the need for close monitoring during labour.

a)

I would enquire regarding antecedent fetal movements prior to this 24hr period. i.e. were fetal movements normal prior to this or have they been decreasing over a longer period and I would also note any previous history of reduced fetal movements.   I would ask about general maternal wellbeing (any flu like symptoms, systemic upset, headache, visual disturbance, abdominal pain).  I would enquire about past medical history, including blood pressure issues, autoimmune conditions, diabetes or other chronic medical conditions.  I would note any medications taken. I would enquire whether the lady is a smoker or uses recreational drugs. 

I would ascertain past obstetric history, noting any obstetric complications along with gestational ages at delivery and fetal weights.  I would ask about any history (family or personal) of genetic conditions.  I would enquire about aneuploidy screening this pregnancy (i.e accepted + result or declined)

I would  note the womans BMI and examine the lady, specifically assessing fundal height (to rule out growth restriction).  I would note any areas of abdominal tenderness .  I would dip urine for proteinuria. I would check BP, temp  O2 saturationsand pulse I would place the lady of a CTG for at least 20 minutes.  If it is not possible to detect FH on CTG I would perform an USS to confirm fetal viability.

b)

I would arrange a formal departmental USS to assess fetal growth, liquor volume along with umbilical artery dopplers.  I would also ensure that fetal morphology has been assessed (i.e. 20 wk scan).  If all parameters are normal I would arrange for x2/wk assessment with umbilical artery dopplers and CTG and going forward repeat growth USS in a fortnight.  At each assessment maternal observations and urinalysis would also be performed.  If any parameters  are abnormal then intervention as necessary-  i.e. absent end diastolic flow (EDF) or pathological CTG would necessitate delivery following steroid cover if maternal condition stable.  Reduced or reversed EDF would necessitate close monitoring and if associated with fetal AC < 5^th centile / oligohydramnios this would also necessitate consideration of delivery.

c)

This lady has proteinuric gestational hypertension (i.e. pre-eclampsia) at term  with a background history of reduced fetal movements.  Ultimately this would necessitate delivery if maternal condition stable, ideally within 24hrs.  Mode of delivery would be dependent on past obstetric history, severity of maternal condition and assessment of fetal wellbeing.

I firstly would ascertain maternal wellbeing, noting any history of headaches, visual disturbance,  vomiting or epigastric pain. I would ask about fetal movements. 

I would palpate the abdomen assessing for epigastric/RUQ tenderness which could indicate hepatic involvement.  I would measure fundal height to give a rudimentary assessment of fetal size/LV.  I would check reflexes and assess for evidence of clonus since neuronal instability of pre- eclampsia can lead to hyper-reflexia and clonus.  I would listen to lung fields and rule out pulmonary oedema.   I would perform a CTG.   I would repeat blood pressure readings to ascertain the degree of hypertension and whether it requires treatment (i.e. if consistently ≥ 150/100mmHg).   I would perform an FBC to look at Hb and platelet count to rule out HELLP.  If evidence of thrombocytopenia (<100,000) I would perform a coagulation profile.  I would check renal and liver function to assess for evidence of end organ compromise associated with pre- eclampsia.  Urates may also be performed which can help complement the assessment for maternal systemic compromise associated with pre-eclampsia.  I would note any previous growth scans.    I would inform the consultant obstetrician of her admission and discuss the possible use of MgSO4 if evidence of severe pre-eclampsia (severe hypertension, clonus, symptomatic with severe headache, epigastric pain/vomiting, HELLP, abnormal biochemistry).   The paediatrician and anaesthetist would also be informed.   Cervical assessment with a view to possible vaginal delivery may be appropriate If the woman is stable with mild pre-eclampsia and no evidence of fetal compromise. 

A)  I WOULD FIRST LIKE TO KNOW IF ANY DATING SCAN WAS DONE AND DETERMINE IF HER DATES ARE CORRECT . I WOULD ALSO LOOK FOR RISK FACTORS FOR STILLBIRTHS SUCH AS MULTIPLE CONSULTATIONS FOR DECREASED FETAL MOVEMENTS PREVIOUSLY IN THIS PREGNANCY. I WOULD ALSO LOOK FOR COMORBIDITIES SUCH AS DIABETES AND HYPERTENSION. I WOULD LOOK INTO THE PAST OBSTETRIC HISTORY AND LOOK FOR PREVIOUS HISTORY OF STILLBIRTHS AND FETAL GROWTH RESTRICTION. I WOULD THEN EXAMINE HER , MEASURE HER BMI , HER BP AND PRESENCE OF PROTEINURIA . I WOULD THEN MEASURE HER SYMPHYSIO-FUNDAL HEIGHT AND SEE IF IT IS APPROPRIATE FOR THE GESTATIONAL AGE. I WOULD THEN AUSCULTATE FOR FETAL HEART BEAT WITH A HAND HELD DOPPLER .

B) SUBSEQUENT MANAGEMENT WOULD INCLUDE DOING INVESTIGATIONS TO DETERMINE THE FETAL WELL BEING . THIS WOULD INCLUDE AN ULTRASOUND BIOMETRY AND PLOTTING THE GROWTH ON A GROWTH CHART TO LOOK FOR EVIDENCE OF FETAL GROWTH RESTRICTION . LIQUOR VOLUME SHOULD ALSO BE ASSESSED AND A CARDIOTOCOGRAPH SHOULD BE DONE TO RULE OUT ANY EVIDENCE OF FETAL COMPROMISE. IF ALL THESE INVESTIGATIONS ARE NORMAL ,  THE WOMAN SHOULD COME FOR SERIAL  2 WEEKLY SCAN FOR FETAL GROWTH. SHE SHOULD BE FOLLOWED UP IN A CONSULTANT LED UNIT AND DECISION TO INDUCE HER LABOUR EARLY SHOULD BE TAKEN INTO ACCOUNT IF THERE IS ANY EVIDENCE OF FETAL GROWTH RESTRICTION  AFTER DISCUSSION WITH THE WOMAN REGARDING THE RISK AND BENEFITS.

C)THIS WOMAN HAS MILD PRE-ECLAMPSIA SHOULD BE ADMITTED FOR IN-PATIENT CARE IN A CONSULTANT LED UNIT .I WOULD ASK HER FOR SYMPTOMS OF IMPENDING ECLAMPSIA SUCH AS HEADACHE , VISUAL DISTURBANCES , NAUSEA , VOMITING AND EPIGASTRIC PAIN . I WOULD THEN PALPATE HER ABDOMEN TO LOOK FOR EPIGASTRIC TENDERNESS AND WOULD ALSO CHECK HER REFLEXES FOR CLONUS AND HYPERREFLEXIA .  I WOULD ALSO MEASURE HER SYMPHYSIOFUNDAL HEIGHT AND CLINICALLY ESTIMATE HER FETAL SIZE. I WOULD ALSO AUSCULTATE FETAL HEART BEAT WITH A HAND HELD DOPPLER. I WOULD THEN TAKE BLOOD INVESTIGATION FOR GROUP AND SAVE ,  FULL BLOOD COUNT TO LOOK FOR HEMOLYTIC ANAEMIA AND THROMBOCYTOPAENIA . I WOULD ALSO DO A UREA AND ELECTROLYTES TEST  ,  LIVER FUNCTION TEST  TO LOOK FOR ELEVATED LIVER ENZYMES AND LOOK AT HER URIC ACID LEVEL . I WOULD ALSO PERFORM A COAGULATION PROFILE TEST IF THERE IS THROMBOCYTOPAENIA .  I WOULD THEN DO A ULTRASOUND SCAN FOR FETAL BIOMETRY AND CARDIOTOCOGRAPHY TEST FOR FETAL WELLBEING .THE AIM FOR THIS WOMAN AT THIS POINT IS DELIVERY ONCE HER BLOOD PRESSURE IS STABILIZED AND HER INVESTIGATIONS ARE NORMAL.I WOULD MEASURE HER BLOOD PRESSURE EVERY 4 HOURS IN WARD AND START ORAL HYPERTENSIVES WITH LABETOLOL IF IT IS = OR > 150/100 persistently . I will consider delivery within 24- 48 hours .There may be need to start her on magnesium sulfate is she exhibits any symptoms of impending eclampsia. She willl need immediate delivery if her blood pressure is unable to be controlled with antihypertensives , maternal symptoms of impending eclampsia or evidence of fetal compromise.

(a)The initial aim is to exclude fetal death and subsequently to detect fetal compromise if fetus is viable as well as to find risk factors for stillbirth .Relevant  history  should be taken to identify pre existing hypertension or diabetes .Detailed obstetric history to find out risk factors of primiparity , previous poor obstetric outcome( stillbirth  or fetal growth restriction).Any history of placental insufficiency or previous placental abruption  is taken.Other factors  as smoking, obesity ,ethnicity,racial predisposition to be noted.Social factors relating to poor access to care is noted.Symptoms of vaginal bleeding ,abdominal pain  should be specifically asked.Review the previous notes if available.

Examination   to find out BMI,blood pressure is  is noted.Proteinuria should be looked for .Abdominal examination  to auscultate the fetal heart with hand held Doppler.Fetal heart needs to be differentiated  from maternal heart rate by simultaneously auscultating the fetal heart and maternal pulse.If feat heart is not confirmed on auscultation,an ultrasound examination is done to confirm fetal viability.

(b) .Cardiotocography for  is done to identify  any fetal compromise .It is  easy and accessible means of find out fetal compromise.If CTG is normal  showing accelerations(  which are present in 92 -97 % of the normal fetuses )..she can be reassured.

If fetal movements remain reduced despite normal CTG,an ultrasound examination is done preferably within 24 hours  for abdominal circumference/estimated fetal weight.Amniotic fluid volume is noted.Fetal morphology assessment is done if it has not been done before and it is acceptable to the mother.

Biophysical profile has a limited role in assessing fetal compromise.It has a good negative predictive value  in high risk women.Umlicalartery Doppler velocimetry is done to identify placental insufficiency.

If the investigations are normal and no risk factors are identified,70% of the women with one episode of reduced feta movements are uncomplicated .She can be reassured  but should be advised to contact  maternity unit if reduced fetal movements  recurs as  recurrent fetal movements is associate with adverse fetal outcome.

© She has preeclampsia with mild hypertension .Admit to the hospital .Assessment should be done by a health care professional traine din the management of hypertensive disorders. Symptoms of severe preeclampsia(headache visual disturbances, epigastric painshould be asked .Observe for any deyerioration in maternal condition .Proteinuria  quantification is not to be repeated Hypertension does not need to be treated .Measurement of blood pressure should be done atleaset 4 times a day to detect any increase in blood pressure  and need for starting anti hypertensives.Renal function tests,Full blood count,Electrolytes ,Transaminases and bilirubin  should be done at admission to detect HELLP or renal compromise.These should be repeated  twice weekly if birth is not planned in 24- 48 hours.

Fetal viability is confirmed .If viable, fetal monitoring is done by CTG,if abnormal inform the consultant obstetricianReview the care plan of the fetal monitoring made earlier.

Recommend birth  within 24- 48 hours   by induction of labour or caeraean section  taking into account maternal wishes ,obstetric history , presence of fetal distress,maternal condition  after advice from the consultant.Discussion with obstetric anaesthetist as well as neonatal paediatrician is done to optimize the neonatal outcome.

If conservative management is planned,ultrasound for fetal growth and amniotic fluid volume also umbilical artery Doppler velocimetry is done at diagnosis.CTG  repeated weekly if results of all fetal monitoring normal.Repeat CTG if any change in fetal movement ,vaginal bleeding ,abdominal pain or deterioration in maternal condition.Inform the consultant for further advice.

A] The absence of fetal movements for 24 hrs should raise a suspicion of  IUFD.  we have to rule out STILL BIRTH or IUGR  . The initial assesment needs a detail history ,  examination and investigations.   Ask the patient since how long are the fetal movements absent .  Has she had a previous episode before .  was she very busy the last 24 hrs and must have not concentrated on her fetal movements .  If she has realised in the morning ,  it must be due to the diurinal variation. since fetal movements have diurinal variation less in morning and peaks by noon and evening .  DId she try to lie down and concentrate on fetal movements  atleast 10 movements in 2 hrs  . Previous obstretic history of still birth or iugr .  If there are any associated medical disorder such as diabetes,  hypertention and  obesity  . any history of congenital anamolies  . can be confirmed by previous anamoly scan , if she has done one .  History of smoking and any recreational drugs  .Decreased fetal  movements  or absent fetal movements is associated with increased risk of perinatal mortality and morbidity.

B] IF the fetus is viable with decreased movements then fetal distress must be ruled out  .  Do a CTG and see the base line variability , acceleration and any deceleration  for about 20 minutes.  If the CTG is reactive ,reassure the patient .  ask her to report  immediately if she has absent fetal movements to an obstretic unit .  If there are no acceleration , Then there must be risk of fetal acidosis and fetal distress . Check Bp  by appropriate size cuff .  Do investigations such as Urine for protien ,  FBC , CRP, GTT , LFT , Urea and creatine , and Clotting profile  . Do a USG for Fetal growthassesment such as amniotic fluid volume, abdominal circumference , fetal weight to rule out macrosomia,  but this may not be accurate  . Uterine doppler studies  .Chart fetal growth and see if iugr . If congenital anamoly is suspected refer her for a higher centre for usg confirmation by an expert .  Provide information leaflet.

C]  This patient is at risk of  Pre eclapsia . ask the patient,   If she has head ache, any visual disturbances, Epigastric pain .  This patient needs admission and delivery within 24 to 48 hrs .  examine the patient per abdomen for fundal height, fetal heart sound ,  presenting part,  any epigastric tenderness.  and any ankel clonus  . she should be admitted in a consultant led unit and multidisciplinary Team for management .   The team should involve Obstretician, anaesthetist, Physician, midwife, and GP, and Neonatologist  .  Start anti hypertensive if Bp >150/100 .   Monitor Bp 4th hrly, check for urine protien by dipstix method and 24 hr urinary protein.  Do baseline investigations such as FBC, Blood group and save, LFT , Urea and creatine.   Clotting profile and Platelet count if patient is going hellp syndrome  . For fetal assesment do CTG , USG for liquor volume.    Do a anaesthetic review .   Discuss the issues about delivery ,  and take her wishes into consideration.    If the patient is stable and no  fetal distress .   Then patient must be induced labour preferably with prostaglandins , if the cervix is not favourable and augment labour with syntocinon .

. if the patient refuses induction ,  then monitor the patient closely with 4 th hrly Bp, urine protein daily  and investigation 3 times per week .  If the clinical conditions deteriorates and patients is going into eclamsia with  Headache, visual disturbances, and epigastric pain ,and uncontrolable hypertension . then perform a ceaserean section .

 or absent fetal movements  is assosiated with increased risk of perinatal mortality and morbidity . 

A) 

History in details to ensure reduced fetal movement, check any risk factors for fetal compromise (diabetic hypertensive,or other medical comorbidity)

Examination includes check bl pr , symphysial fundal height (if less than expected) suggest fetal growth restriction FGR. check fetal heart beat by hand held doppler if not heard request US to check fetal viability

review patient record to check results of anomaly scan

if patient is not sure of reduced movement ask her to lie down for 2 hours & count fetal movement i t..10 or more movements are reassuring &if less request CTG.

if movements are => 10 & there are no other risk factors  she can be reassured  & tocome again if another episode of reduced movement.

b)CTG is infomative about the time of application but has high fals +ve results &poor prediction

US is recommended to check fetal growth liquir volume . Biophisical profile is informative but again has poor prediction & time consuming 

umbilical artery doppler study is more accurate with good prediction, reduced absent or reversed end diastolic volume is indicative of fetal compromise.doppler of middle cerebral artery is also accurate in predicting fetal cmpromise.

abnormality in CTG,  doppler studies are indication of admission with further assessment.

c) preeclampsia 38w with attack of reduced fetal movement at 34w is an indication of addmission for further assessment &monitoring.

assess severity of maternal condition,(severe headache, epigastric pain signs of eminent eclampsia) assess fetal wellbeing by CTG, US, doppler study

Monitor patient vitals with regular check of bl pr urin outpot , guard againest fluid overload by input output chart.  request FBC liver function tests kidney function tests coagulation profile group &save

control bl pr by B blooker (labetolol0 or CA channel blooking agents (nifedipine)

If eminent eclampsia start Mg sulphate & tremination of pregnancy is considered

 if patient condition is stable nofetal distress so this is mild preeclampsia patient can bf followed till spontaneous delivery.

CS for obstetric indication or fetal distress.

A)

Detirmine her risk for stillbirth. Ask her parity. Stillbirth is increased with nulliparity. Ask about outcomes of her previous pregnancies. Prior stillbirth or fetal growth restriction increases the risk of fetal compromise. Ask whether she was at rest. Maternal perception of fetal movement is reduced when not at rest. Ask whether there were prior episodes of reduced fetal movement. Recuurent episodes is associated with adverse fetal outcome. Ask whether she has diabetes in pregnancy and whether she smokes cigarettes. These predispose to stillbirth. Drugs such as benzodiazepines, opiates, methadone or corticosteroids decrease fetal movements. Ask if she has taken these recently. Read her antenatal notes. Look for ultrasounds showing fetal anomalies, growth restriction or oligohydramnios. These findings predispose to fetal compromise/stillbirth. On examination measure her blood pressure and calculate her BMI. Hypertension and obesity predispose to stillbirth. Measure her fundal height. Small for gestational age may indicate fetal growth restriction. Detirmine the fetal position. Maternal perception may be decreased if the fetal back is anterior. Confirm fetal viability with an audible heart rate using the doppler probe.

B)

Inform the consultant and refer to a fetal medicine specialist. Her management should be individualised. Explain that evidence advocating intervention or investigation for reduced/absent fetal movement is lacking. Explain that recurent episodes of reduced movement is associated with adverse fetal outcome. Recognise maternal anxiety and offer counselling if appropriate. Perform a Cardio-Tocograph (CTG) and ultrasound for fetal biometry and liquor volume. Assess her attitude toward anomaly scans. Offer an anomaly scan if she agrees. If investigations are normal reassure her of a 70% chance of good fetal outcome. Offer induction of labour at term. Ensure that the consultant counsels her regarding pros and cons of induction of labour. Explain that delivery at term avoids the complications of prematurity( NND, NEC, RDS, IVH, Sepsis, NICU admission). Offer increased surveilance through weekly clinic visits. Offer written inormation and hospital contact numbers.

C)

This is pre-eclampsia at term. Admit to the antenatal ward. Inform the consultant and nurse in charge. Explain the diagnosis and need for delivery. Assess for symptoms and signs of severe pre-eclampsia. Ask her about symptoms which include headaches, blurred vision, nausea, vomitting, epigastric or right upper quadrant abdominal pain. Ask about decreased fetal movement. This may indicate fetal compromise. On examination ellicit signs of severe pre-eclampsia. These are epigastric or right upper quadrant tenderness, ankle clonus and hyper-reflexia. On abdominal exam, comfirm cephalic presentation and measure her symphysio fundal height. Calculate her BMI. Blood investigations include Complete Blood Count (CBC), renal and liver function tests (RFT/LFT's), blood for group and to be saved. Anaemia with elevated liver enzymes and thrombocytopenia indicate severe pre-eclampsia with HELLP syndrome. Perform a CTG to assess fetal well being.If signs or symptoms of severe pre-eclampsia administer MgSO4 prophylaxis and continue for 24hours to prevent eclampsia. Offer delivery urgently. Decision regarding mode of delivery should be individualised after consultant review. If there are no signs/ymptoms of severe pre-eclampsia treat as mild pre-eclampsia. Offer induction of labour within 24-48 hours. Monitor blood pressure  at least every 6 hours. Ask about signs of severe pre- eclampsia at every measurement. Start oral Labetolol if blood pressures above 150/ 80-100 mmHg and aim for blood pressure <150/100 mmHg. Assess her risk for thrombo-embolism using a proforma. Offer TED sockings and advise ambulation. Offer written information.

in part C i meant aim for BP 150/80-100 and treat with labetolol if BP >150/100mmHg

From history, I would ask regarding if she has other symptoms currently such as abdominal pain, vaginal bleeding or leaking liquor. I would ask if she has any recent itchiness especially over palms and soles, pale colored stools or dark urine. I would ask if this is her first episode of reduced fetal movements, any prior abdominal trauma or recent upper respiratory tract or viral illness. I will ask if this current pregnancy, any fetal anomalies on detailed scans, any abnormal results with any down’s syndrome screening, any pregnancy induced hypertension, gestional diabetes, recurrent antepartum haemorrhage or obstetric cholestasis. I would ask if she has pre-existing medical conditions such as anemia, thyroid disorders or diabetes mellitus, myasthenia gravis and how well it is controlled. I will ask if she is taking any recreational drugs, smoking and alcohol intake. I will ask on past obstetric history such as number of children, any previous stillbirths or fetal losses, birthweight of children, any antepartum problems.

For physical examination, I would assess her body mass index, blood pressure and urinalysis for protein. I would palpate her uterus for tenderness and assess symphyseal fundal height. I would check for vaginal bleeding or leaking liquor. I would assess fetal heartbeat with handheld Doppler. I would reassure the patient with a sensitive approach and later discuss my findings.

b)

I would perform a CTG for the patient to assess if it is reactive. I would perform an ultrasound to assess liquor volume, umbilical artery Doppler indices and biophysical profile. If all results normal, I would reassure patient and allow her to go home. I would advice her to lie on her side and monitor fetal movements for 2 hours, if less than 10 movements felt, to return to hospital immediately. I would provide written information and supportive counselling, and 24h hotline telephone number to call if she has reduced fetal movements.

c) Patient has pre-eclampsia. I would explain the findings to the patient and need for control of blood pressure. I would admit the patient to hospital with consultant led maternity unit. Multidisciplinary care is needed from midwives, anesthetists, obstetrician experienced with dealing with hypertension in pregnancy. I would monitor patient’s blood pressure, heart rate 4 hourly on modified early obstetric warning chart and her fluid input/output. I would set a intravenous cannula and take blood tests: full blood count, renal panel, liver function tests, group and save. I would start antihypertensive medication if her blood pressure is above 150/80-100 mmHg with first line being labetalol. I will ask her on symptoms of impending eclampsia such as blurring of vision, headache or epigastric pain, if she has these symptoms, to inform the team immediately. I would monitor the fetus with CTG daily. I would perform ultrasound to assess if umbilical artery Doppler indices, growth and liquor volume. I will discuss with patient regarding induction of labor as she is term and has pre-eclampsia. I will explain risks of induction of labour including risk of cord prolapse, fetal distress due to uterine hyperstimulation, emergency caesarean section. I will discuss mode of delivery: she can have normal vaginal delivery; caesarean section if other obstetric indications. I will provide written information and information on support groups and counselling. I will assess her risk for venous thromboembolism, if she is at risk I will start her on thromboprophylaxis or thromboembolic deterrant stockings.

a)   Initial assessment is by asking the woman if she can feel  fetal movement after coming to unit. She is asked about any previous episodes of reduced fetal movements (RFM)  . Assess risk for  stillbirth and fetal growth restriction (FGR). History of preeclampsia   , diabetes would increase the risk .

 Previous obstetric outcome like stillbirth ,FGR  would also add to the risk. She is asked about smoking,  drug abuse which can lead to growth restriction and reduced movements.Her notes reviewed ,any scans noted.

Examination includes BMI as obesity increase risk of stillbirth, blood pressure measurement .  Abdominal exam done any uterine tenderness noted.

Symphysiofundal height  measured and compared to  customized charts .  Assess fetal  size.  Fetal heart documented with hand held Doppler .

If fetal heart present,   no risk factors and fetal movement felt she is reassured. If fetal heart not heard refer for urgent ultrasound for cardiac activity.

b) If fetal movements remain reduced further assessment is needed which includes CTG (cardiotocograph) recording of fetal heart . Presence of accelerations with fetal movemnts is reaasuring.

Ultrasound for growth ,estimated fetal weight, amniotic fluid , done to detect any growth restriction .  Umbilical artery Doppler may be useful if any fetal growth restriction.

Biophysical profile has limited value, if normal fetal death rare.

The woman is reassured if all parameters normal. In case of growth restriction ,dopplers changes  refer to consultant for management.

If two or more  episodes of reduced movements  outcome may be poor and decision to deliver is consultant based after discussion about neonatal outcome if preterm and chance of failed induction

c)      This woman has developed mild preeclampsia and should be admitted for further evaluation  for mother and fetal well being in consultant led unit.

       Measure blood pressure (BP) every 6 hours with appropriate size cuff.        

       Ask for symptoms of severe preeclampsia like headache,   vomiting  ,epigastric   pain blurring vision at time of bp recording . 

       Do not repeat protein quantification  after admission . Full blood count , urea electrolytes, serum creatinine, transaminases,bilirubin  twice a week.   If platelets less than 100x10 9/L coagulation screen done.

Labetalol is first line anti hypertensive if blood pressure more than 150/100. No antihypertensive needed at this BP.

If she has severe preclampsia symptoms  like headache , abnormal lab values like liver enzyme ALT alanine transferase>  70 U/L, platelets <100x 10 9/l, Hellp syndrome  magnesium sulphate to prevent fits  should be considered.

Cardiotocography  of fetus  at admission and repeated if change in fetal movement ,  pain  abdomen .

Plan delivery in 24-48 hours as she is term  by the consultant. Vaginal delivery is recommended unless obstetric indications

Offer written information about preeclampsia , complications like eclampsia ,

need for postnatal follow up of blood pressure measurement 

a) History  should  aim  at  identifying  risk  factors  for  intrauterine  fetal  death  and  fetal  growth  restriction.She  is  asked  if  it  is  the  first  episode of RFM or  recurrent  episode.Prior  obstetric  outcome including  IUFD  and FGR  is  enquired.Risk  factors  including  presence  of  hypertension,diabetes  mellitus are  assessed.Review  her  antenatal records  for assessement  of  fetal growth  and  prior diagnosis  of  FGR.Drug  history  of  antidepressants,opiates  which  can   cause  reduced  movements  is asked.Social  factors  smoking ,alcohol intake  can cause  RFM. Assessment  of  fetal  heart  rate  is  done  with  hand  held Doppler.Fetal  heart  rate  is  correlated  with  maternal pulse rate.If  doubt  persists  ultrasound  is  done  to  check  fetal heart  rate.Symphysiofundal height is  measured  using customized  charts for detecting FGR.  BP  and  urine  for  protenuria  is  done  due  to  association  of  preeclampsia  with FGR.

b)  CTG  monitoring  is  done  to  assess fetal  compromise.  CTG  is  reactive  with  accelerations,no  decelerations,base  line  variability of  more  than  5beatspm,BLHR 110- 160bpm. If  CTG  reactive,no  additional  risk  factors  for FGR  and  she  perceives  fetal  movements  she  is  reassured  .She  is  advised  to  report  if  further RFM  are  present.  If  she  continues  to  perceive  reduced  movements inspite of  reactive CTG  ultrasound  assessement  is  necessary. If  risk  factors  for  FGR is  present  ultrasound  is  necessary.It  is  arranged in  24  hrs .It  includes  assessement  of  liquor,abdominal circumference,weight  and  morphology  if  not  done. If  normal  she  is  ressured  that  outcome  is  good  in  70%  of  the  cases.She  is  advised  to  report  if  further  reduced  movements.She  is  explained  that  there  is  no  formal fetal count.Biophysical  profile inspite of good  negative predictive value  is  not  routinely  done  due  to  lack  of  sufficient  evidence.

c)Due  to  moderate  preeclampsia   and  term  gestation  she  requires  admission  and  assessment. She  requires  delivery  in  24 to 48  hrs. History  includes  presence  of  imminent symptoms headache,blurring  vision, flashes  of  light ,vomiting ,epigastric pain.Presence  of  imminent  symptoms  warrant  Level 2  care.Presence  of  fetal  movements  is   asked. Examination  includes measurement  of BP with appropriate cuff,BMI. Refexes,visual fields,presence  of  clonus  checked .Abdominal  examination  includes SFH measurement  for  IUGR,presentation,fetal size,epigastric tenderness and  uterine tenderness Investigations   include  FBC,urea and  electrolytes,LFT. CTG  is  done  for  assessing  fetal  well  being.

Ensure  consultant is  informed.Treatement  includes  antihypertensives with  oral  labetalol.Aim  for  BP systolic less than  150mmHg and  diastolic 80-100 mmHg.Monitor BP 4^th hrly.Assess  for  imminent signs  and  symptoms.Risk  for  VTE  is  assessed  .TED  stockings  and  mobilisation  encouraged.Plan  for  induction  of  labour  in  24-48 hrs if  no  obstetric  indications for cesarean section.If   imminent signs are present,derangement of parameters  ,uncontrolled  HT   she is  monitored  in level 2 care with multidisciplinary care intensivist,hematologist,obstetrician,anesthetist

.Prophylactic  intravenous  magnesium sulphate  is  considered if appropriate.

A 23 year old woman attends the day assessment unit at 34 weeks gestation because she has not felt fetal movements for 24 hours. (a) Discuss your initial clinical assessment [6 marks]. (b) Discuss your subsequent management if the fetus is viable but movements remain reduced [5 marks]. (c) She presents at 38 weeks gestation with BP of 148/98 mmHg, 3+ proteinuria and urine protein:creatinine ratio of 256 mg/mmol. Discuss your antenatal management [9 marks].

A/

The aim of the initial assessment is to find out   any risk factors for poor perinatal outcome ( FGR/STILL BIRTH) .

I would inquire about history of repeated episode of reduced FM ,the woman age as extremes of age is associated with poor out come ,history of diabetes , history of hypertension that may result in placental insufficiency and hence poor out come , history of poor obstetrical out come such as sill birth or FGR (fetal growth restriction) ,history of smoking , history of congenital anamoly detected in previous anamoly scan. 

I would examine the woman for the BMI ,bp, symphysio fundal hight to detect any growth restriction.

Then  would confirm the viability using hand held doppler device ,and here the FHS should be deferentiated from the mother hear rate  by palpating the mother pulse at the same time .Then would assess the fetal wellbeing  by CTG  which would be reassuring if there is accelaration of the FHS with the fetal trunkal movement which indicate  healthy fetal CNS , this should be carried out for at least 20 minutes .If no accelaration, the CTG should performed for 80 minutes if still no acceleration then this  would be associated with poor perinatal out come and further invistigation is needed .

U/S for growth,liquor volume and umblical artery doppler study  would be performed with in 24 hours  of the woman presentation if there is risk factors of poor out come or if there is  no acceleration in the CTG for 80 minutes. 

If there is acceleration in the is 20 minutes of the CTG  and there are no risk factors for poor out come then the woman would be reassured and advice to report back to the maternity unit if there is further reduction in fetal movement perception.Fetal movement alarm limit chart is not benifecial and associated with increase mother anxiety.

B/

Repeated episode of reduced  FM is consider risk factor for poor out come (still birth/FGR)  even in the absence of other risk factors.

The woman should be re examined{ bp,symphysiofundal hight,}.

Then CTG  should be done as well as u/s for growth ,liquor volume and umblical artery doppler flow.

If the result still normal the  the woman would be  counselled(under consultant lead )  regarding induction at 37 wk and the pros and cons of  induction will be discussed.

If the result are abnormal  then the time of delivery the mode ,and the frequency of the invistigations would be determined  by the the senario all together.

If the fetus is to be delivered before 34 wk + 6d the steroid should be administered

c/

This protenuric hypertention at term , the wouman should be asked about headache epigastric pain , bluring of vision and vomitting { feature of emminent eclampsia ),and she should be examined  for viabilty  by hand held doppler device . the fundal hight would be assessed for growth restrction .  The feet would be tested for clonus.

The fetal wellbeing should be tested by CTG .

BP would be measured 4 times/day. the woman would be invistigated  CBC , RFT , LFT, and blood for groub and safe .

No need for antihypertensive treatment at this stage , only if the blood pressure shoot above 150 systolic and  100mmg diastolic.

The woman should be delivered with in 24- 48 hours from admission, the aim is for vaginal delivery ,so should be induced with continous CTG monitoring . C/S would be done if there are clear indication  such severe IUGR, or pathollogical CTG .

a/ My initial clinical assessment depends on viabilty of the fetus. fetal viability confimed by hand held doppler. Then take comprehensive history to exclude any still birth and other risk factors including placental insufficeny fo( gestational hypertention) and ,SGA,smoking, inaddition, DM,Obs cholestasis & congenital malformation may reduces the fetal movement also. enquire about past history of reduce fetal movement, SGA, gestational hypertention. futher more   abdomial examination &  palpation and symphysio-pubic hieght measurement to exclude SGA.

b/ If fetal movement still reduced then subsequent mangament will be 20 minutes CTG to assess fetal compromised. If there is accelerations then baby is active and reassurance provided to mother. However persistent RFM after CTG, then i will do ultrasound. During scanning assessing, fetal growth, abdominal cirumference, EFW, & amniotic fluid index & dopplers to exclude SGA & hypertention & still birth. Biophysical profile can be performed but lessvalue in RFM.

c/ Pt has pre-eclampsia at 38 weeks with significant protienuria, admit her for observation. take breif history of smoking, headache, blurring of vision,epigastric pain & nausea ,past history of pre-eclampsia aswell. on examination abdominal examination and palpation & hieght  of  fundus to exclude  SGA. for assessment of brisk reflexes I will check Knee & ankel reflexes. I will do CTG for fetal compromised. I will do U/S to asses fetal circumference, EFW, liqour voilume and Dopplers as well. Although dopplers is best perform in SGA but as pt has RFM just for reassurance. As BP is moderately high, and assessment of BP 4hourly. I will send investigation of FBC, LFT, U&Es. As protienuria is already 3 + so will commence anti hypertensive medication. As pt has RFM i will discussed dellivery option. I will counsel her for induction of labour,or ceaseran section.

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A)     Reduced foetal movements may be a sign of foetal compromise. History has to be taken regarding the risk factors for still birth and IUGR, assess for obesity, if she is addicted to smoking. Ask her previous obstetric history, primiparity and so poor obstetric history predisposes to poor perinatal outcome. Ask for if she had any chronic medical conditions like diabetes, hypertension, or thrombophilia which may predispose her to preeclampsia and IUGR.  Ask if in past also she had similar episode of reduced foetal movements. Review her antenatal records and see if she had received corticosteroids 2-3 days before, which may cause reduced foetal movements and if USG shows any anomaly in the  foetus. Examination must be thorough, including BP measurement. for evidence of gestational hypertension.Abdominal examination should be done to look for the fundal height, if corresponds to gestational age (evidence of IUGR). Auscultate foetal heart with hand held Doppler .Perform CTG to assess for the foetal well being.

B)      If movements remain reduced and the foetus is viable, BP should be measured  with appropriate sized cuff. Test urine for poteinuria, to exclude pre eclampsia. CTG should be done for atleast 20 minutes and assess baseline foetal heart, variability, accelerations. If there are no foetal accelerations for 80 minutes, foetal compromise is likely. Do abdominal examination to assess the fundal height, for evidence of IUGR and position of foetus. Anteriorly placed spine of foetus may cause difficulty to mother in perception of foetal movements. Ultrasound scan should be done immediately if despite normal CTG, movements remain reduced and assess the liquor volume, position of placenta, estimated foetal weight, abdominal circumference. Foetal anomaly scan should be done if not performed previously.

C)      BP of 148/98 mmHg, 3+ proteinuria and urinary protein : creatinine ratio of 256 mg/mmol makes a diagnosis of preeclampsia with mild hypertension. Patient should be admitted in the maternity unit and provide critical care level 1. Consultant obstetrician should examine her for the first time. BP should be measured in right arm in semi- recumbent position at the level of heart with appropriate sized cuff. BP monitoring should be done every 6 hourly. Neurological examination should be done and examine the reflexes as they may have hyper-reflexia. Abdominal examination should be done, assess the fundal height to see for the evidence o f IUGR.CTG should be done at the time of diagnosis and if normal repeat only weekly or if she had abdominal pain, vaginal bleeding, reduced foetal movements.

 Send blood tests, FBC, LFT,RFT, electrolytes,group & save at the time of diagnosis and repeat twice in a week to assess if she does not develop HELLP syndrome. Test urine daily for proteinuria. Send 24 hour urine for proteinuria as it is a reliable marker. USG scan should be done to assess the foetal well being, liquor volume and umbilical artery Doppler must be done at time of diagnosis and if abnormal,inform consultant obstetrician. No anti- hypertensives are required to prescribe.

Explain her about the warning signs of severe pre eclampsia and eclampsia , blurring of vision, flashing of lights, severe headache, nausea and vomiting, pain below the ribs, which may require termination of pregnancy. Document the maternal and foetal thresholds which may require termination of pregnancy. Discussion should be done with consultant neonatologist, anaesthetist about the outcome of baby, required analgesia during delivery and write a care of plan. Discuss about the mode of delivery and requirement of ICU admission of mother, NICU admission of baby. Delivery is recommended within 24-48 hours of diagnosis beyond 37 weeks, depending on the maternal and foetal condition, risk factors and availability of neonatal intensive care.

A) The woman’s risks for stillbirth and foetal growth restriction (FGR) should be assessed. She should be asked if it is the first episode of reduced foetal movements (FM) or she has had previous similar episodes and her obstetric notes should be reviewed for the details. Previous ultrasound scan reports should be reviewed to check if the foetus is small for gestational age. Other factors like hypertension, diabetes, anemia, placental insufficiency causing oligohydramnios and FGR, metabolic disorders, hypothyroidism, smoking and raised body mass index should be checked for.  Certain medications can cross placenta and reduce FM like benzodiazepines, barbiturates, and methadone. Alcohol and narcotics can also be responsible. Foetal malformations including musculoskeletal abnormalities should be ruled out. Also her racial, ethnic and social background, busy schedule and history vaginal bleeding, leaking suggestive of ruptured membranes should be considered. Abdomen palpation and symphysiofundal height measurement can give an idea about small for gestational age foetus, oligohydramnios or polyhydramnios. Hand held Doppler should be used to check foetal cardiac pulsations. If foetal heart beat is present, Cardiotocograph (CTG) should be performed to confirm foetal wellbeing.

B) If the foetus is viable but the movements remain reduced, CTG should be performed to diagnose or exclude foetal compromise. CTG is normal if baseline rate is between 110-160 beats per minute, beat to beat variability of 5 or more beats, with accelerations and no decelarations. If the CTG is normal and she still has reduced FM or has risk factor for stillbirth or FGR, then an ultrasound scan should be performed to measure the liquor volume, abdominal circumference and estimated foetal weight. A detailed foetal morphology scan should be performed if not done previously and the woman is willing. If any abnormality is detected on the Ultrasound scan, then it should be managed according to the agreed unit protocol. If CTG and ultrasound is normal and she no longer has reduced FM and she is not high risk for still birth or FGR, then she should be reassured. If she is unsure about reduced FM, she should be advised to lie in left lateral position and focus on FM for 2 hours. If in these 2 hours she experiences less than 10 movements, she should contact the maternity unit. She should be given appropriate verbal information backed by written information. If the CTG is suspicious or pathological, it should be managed according to the unit protocol

C) As this woman has preeclampsia, she requires admission to the hospital. She should be asked for presence of headache, visual blurring or flashes of light, nausea, vomiting, epigastric pain. Appearence of these symptoms indicates worsening preeclampsia. She should also be asked for vaginal bleeding, abdominal pain and reduced foetal movements. Examination should include Blood pressure measurement. This should be repeated at least 4 times a day while she is inpatient. Neurological examination should be done to check reflexes. Hyperreflexia or clonus in ankle or knee indicates worsening of the disease. Abdominal palpation and symphysiofundal height measurement may give an idea about possibility of small for gestational age foetus and oligohydramnios. Epigastric or liver tenderness may be present in worsening disease. Papilloedema can be seen on fundoscopy in severe disease. Blood should be sent for full blood count, renal function, electrolytes, transaminase and bilirubin. These tests should be repeated twice a week in mild preeclampsia. Repeat testing for quantification of proteinuria is not required. Coagulation profile should be checked only if the platelet level is less than 100 x 10^6/L. Cardiotocograph should be performed to diagnose or exclude foetal compromise. Ultrasound scan can be performed if there are concerns regarding estimated foetal weight and liquor volume. The consultant obstetrician should be informed. Since she has mild hypertension at present, antihypertensive therapy is not indicated. However if the systolic blood pressure is equal to or more than 150 mm Hg and/or diastolic is equal to or more than 100 mm Hg, then antihypertensive therapy should be started. Oral labetolol is preferred as first line. Since she is 38 weeks with mild preeclampsia the risk of prolonging the pregnancy outweigh any benefits. So she should be counseled about delivery within 24-48 hours. Induction of labour is a suitable option. Caesarean section is for obstetric indication.  Woman’s wishes must be taken into account. In case of worsening of clinical features, deteriorating blood picture or fetal compromise immediate delivery is required. If she is at high risk of eclampsia or, severe preeclampsia develops and decision to delivery is made then prophylactic magnesium sulphate should be started and continued for 24 hours following delivery.

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